Inter-prescriber variability in the decision to prescribe antibiotics to febrile patients attending primary care in Myanmar

Abstract

Background Most antibiotic prescribing occurs in primary care. Even within the same health facility, there may be differences between prescribers in their tendency to prescribe antibiotics, which may be masked by summary data. We aimed to quantify prescriber variability in antibiotic prescription to patients with acute fever in primary care clinics in Myanmar. Methods We conducted a secondary analysis of prescribing data from 1090 patient consultations with 40 prescribing doctors from a trial investigating the effect of point-of-care C-reactive protein (CRP) tests on antibiotic prescription for acute fever. We used multilevel logistic regression models to assess inter-prescriber variability in the decision to prescribe antibiotics. Results The median odds ratio (MOR) in the unadjusted model was 1.82 (95% CI: 1.47–2.56) indicating that when two prescribers from this population are randomly selected then in half of these pairs the odds of prescription will be greater than 1.82-fold higher in one prescriber than the other. The estimated variability from this sample of prescribers corresponds to a population of prescribers where the top 25% of prescribers will prescribe antibiotics to over 41% of patients while the bottom 25% will prescribe antibiotics to less than 23% of patients. Inter-prescriber variation in antibiotic prescribing remained after adjustment for patient characteristics and CRP information (P < 0.001). Conclusions Despite sharing the same management guidelines, there was substantial inter-prescriber variation in antibiotic prescription to patients with acute fever. This variation should be considered when designing trials and stewardship programmes aiming to reduce inappropriate antibiotic prescribing.

Factors contributing to the variation in antibiotic prescribing among primary health care physicians: a systematic review

“…Another study [ 27 ] noted that physicians frequently overprescribe antibiotics due to patient expectations and preferences. The expectation and preference of patients who have previously received antibiotics have an effect on the decision of physicians [ 12 , 32 , 34 , 42 , 52 ].…”

“…Quantity and quality of service were also associated with antibiotic prescribing practices and variability of prescribing antibiotics in primary health care physicians [ 46 , 58 ]. Weak regulation of health systems, the dissemination of medical information, and practice setting characteristics (such as location, level of activities, network participation, and continuing medical education) influenced antibiotic prescribing [ 30 , 32 , 33 , 47 , 58 ]. Chem, et al [ 54 ] reported that the external pressure of the pharmaceutical industry and over-the-counter antibiotics were factors that influenced the prescribing of antibiotics by physicians.…”

“…However, a study conducted in Canada reported that the inter-physician variability in prescribing antibiotics could not be explained by patient preference and patient sociodemographic characteristics; rather, it is likely to be related to individual physicians’ prescribing habits [ 12 ]. Clinical setting and management were also important factors for inter-prescribing variability in the decision to prescribe antibiotics [ 12 , 32 , 34 , 42 , 52 ].…”

“…This study also reported that specialized paediatric physicians were more likely to adhere to guidelines for managing the treatment and less likely to prescribe antibiotics without positive tests. The included studies also showed that the majority of practice-level variation in antibiotic prescribing was explained by the variation in physicians’ individual practice patterns, perceptions, attitudes, and knowledge [ 12 , 18 , 32 , 42 , 43 ] (as shown in Table 2 ). According to Tang, et al [ 59 ], exposure to different medical cases can have a favourable impact on the variability of antibiotic prescribing patterns of physicians for upper respiratory tract infections.…”

Outpatient Antibiotic Prescriptions in France: Patients and Providers Characteristics and Impact of the COVID-19 Pandemic

“…In Europe (Greece, Sweden, Switzerland, UK, Spain) several analyses using medical-administrative databases have shown that individual patient characteristics were associated with antibiotics prescriptions [13,14,[19][20][21][22]. In addition, several studies reported differing providers practices in the US [23], Canada [24], or Asia [25], suggesting that physicians' preferences influenced prescribing decisions independently of the patient's condition. Furthermore, the significant reduction in prescriptions observed during the COVID-19 pandemic in several countries including France [26][27][28][29] suggests that there is room for progress in reducing the volume of antibiotics dispensed in the outpatient sector in the context of a full care offering.…”